Social Worker, MSW

About the role

The Social Worker, MSW plays a crucial role in providing comprehensive social work services to participants and their caregivers at InnovAge. Services include conducting psychosocial assessments, participating in care planning, and acting as a liaison between participants and the interdisciplinary team. This role involves both on-site and field-based work, including home visits and coordination of care.

Responsibilities

• Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
• Completes in-person reassessments at least every six months or as required.
• Performs in-home visits as required by regulations or as indicated.
• Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
• Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
• Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
• Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
• Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
• Documents housing encounters in EPIC.
• Collaborates with comfort care team for end-of-life activities.
• Aids in end-of-life coordination for participants' families.
• Collaborates with RN Case Management on hospitalizations, providing psychosocial input.
• May serve as back-up to RNCM.
• Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; manages admission holds and urgent rehousing.
• Collaborates in guardianship process for participants lacking decision-making capacity without a surrogate.
• Obtains SNF/ALF updates for IDT, manages respite scheduling, and supports placement transitions.
• Provides options counseling when appropriate.
• Aids participants who are disenrolling by assisting with timely referrals to external services and completing disenrollment paperwork.
• Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated.
• Completes comfort care assessments and provides guidance on transitions to end-of-life services.
• Advocates for participants living in unsafe housing conditions.
• Contributed to RCA development, incident reporting, and follow-up for abuse, neglect, exploitation, and elopements.
• Assists participants and caregivers with grievances and appeals, explaining rights and processes.
• Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.
• Maintains accurate and timely documentation in Epic, EireneRx, and other systems.
• Completes PASSR screenings, supportive housing forms, and other mandated documents within regulatory timelines.
• Supports Medicaid eligibility recertification processes, collaborating with Eligibility Financial Determination teams.
• Escalates service recovery when needed for a participant concern or disenrollment.
• Ensures all participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.
• Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
• Provides community education and participates in external support groups, inter-agency coordination, and partnership meetings with RCFEs.
• Coordinates with facilities on participant needs.
• Provides caseload coverage support as assigned for MSW PTO, open FTEs, and general team needs.
• Performs other duties as assigned.

Qualifications

• Master’s degree from a school of social work accredited by the Council on Social Work Education.
• Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) from The New Mexico Board of Social Work.
• One year experience in a health care setting, including conducting psychosocial assessments, care planning, and case management skills.
• Experience working with the frail or elderly.

Benefits

InnovAge offers a comprehensive benefits package, including medical, dental, vision, 401(k) plan with company match, short and long-term disability, life insurance, supplemental life insurance, ADD, flexible spending account, paid time off, and company-paid holidays. InnovAge is committed to equal opportunity and affirmative action, and strives to create a diverse and inclusive workplace.